Previous research has outlined how early discharge of low-risk patients with heart attack (acute myocardial infarction) is feasible after four days hospital stay, and can be achieved at no additional risk of adverse events. Padma Kaul from Alberta University, Canada, and colleagues from the Virtual Coordinating Center for Global Collaborative Cardiovascular Research (VIGOUR) assessed the extent to which different countries have taken advantage of the opportunity for early discharge.
The investigators analysed the hospital discharge data of over 50,000 people who took part in previous randomised trials (GUSTO-I, GUSTO-III, and ASSENT-2) covering the years 1990-98; these studies enrolled patients with heart attack in the USA, Canada, Australia, New Zealand, Belgium, France, Germany, Spain, and Poland.
The rate of early discharge of eligible patients was consistently low (less than 2%) in Belgium, France, Germany, Spain, and Poland, although the number of eligible patients discharged on or before day 4 increased in the USA, Canada, Australia, and New Zealand. Despite this increase, no more than 40% of patients who were eligible for early discharge were actually discharged early. In the most recent trial (ASSENT-2) the number of potentially unnecessary hospital days (per 100 patients enrolled) ranged from 65 in New Zealand to 839 in Germany.
Padma Kaul comments: "Despite more than a decade of research, there is still a lot of variation between countries in international length-of-stay patterns in acute myocardial infarction. The potential for more efficient discharge of low-risk patients exists in all countries investigated, but was especially evident in the European countries included in the study."
Discussing the UK perspective, Adam Timmis and colleagues from London's Chest Hospital conclude in an accompanying Commentary (p 502): "The management of acute myocardial infarction and other high-risk coronary syndromes is moving increasingly towards percutaneous intervention at admission or in the first 24 h. At present, resources in the UK, in terms of catheter laboratories and trained interventional staff, are insufficient to meet this standard of care, with the result that many high-risk patients stay in hospital even longer than those reported on by Kaul and colleagues, while they wait for catheter laboratory access. With adequate resources, however, primary angioplasty and stenting, which will unify hospital management under a cardiological team, could improve still further the cost effectiveness of early discharge for acute myocardial infarction. Such models for day 3 discharge in uncomplicated cases have been suggested."
Contact:
Dr Padma Kaul PhD, University of Alberta, 7221 Aberhart Center - I, Edmonton, AB, T6G 2B7, CANADA;
T) 780 407 8680; F) 780 407 8368;
E) pkaul@ualberta.ca;
or Dr. Paul W. Armstrong MD, University of Alberta, 2-51 Medical Sciences Building, Edmonton, AB, T6G 2H7, CANADA;
T) 780 492 0591; F) 780 492 9486;
E) paul.armstrong@ualberta.ca
Dr Adam D Timmis, Department of Cardiology, London Chest Hospital, London E2 9JX, UK;
E) timmis@lch.demon.co.uk
Journal
The Lancet